From the Hippocratic Oath to the Declaration of Geneva: the eclipse of God in Medical Ethics
Gonzalo Herranz, department of Bioethics, University of Navarra.
lecture Delivered at the workshop on Health Conscientious Objection.
Pamplona, 23 September 1995.
1. The transition from Oath to Declaration
2. The disappearance of respect for man
3. Why does the eclipse of God manifest itself so intensely in medicine?
I confess that it is with trepidation, with great trepidation, that I present this paper. The years I have spent studying, teaching and applying the professional ethics of medicine have not made me a philosopher, not even at its Degree minimal amateur level. I am still a doctor through and through. I do not know whether this will earn me your benevolence or impatience, which is what intruders usually provoke. It is always possible to take refuge in the interdisciplinary. The organisers are ultimately responsible for having found interesting the degree scroll that I suggested some time ago for my intervention.
One thesis is on my mind, a problem that will require a lot of historical research and no little medical-ethical reflection: that of degree scroll of my intervention: the significance of having replaced the Hippocratic Oath with the Declaration of Geneva. In my opinion, it has led to the eclipse of God in the institutional ethics of medicine. And now we are seeing it, the eclipse of man.
How God was left aside in 1948, without anyone protesting, when the professional ethics of contemporary medicine were programmed in Geneva. 2. The marginalisation of God in the current internship of medicine, taking the example of euthanasia in the Netherlands. 3. Some reasons why medicine is the profession where the eclipse of God manifests itself earliest and most intensely. 4. I will end my speech with an act of hope.
1. The transition from Oath to Declaration 
Fifty years ago now, the last battles were being fought on the European stage of the Second World War. In the course of the war, alongside heroic gestures of self-sacrifice and righteousness, doctors were involved in some shocking abuses, as the war crimes trials revealed. The atrocities committed by doctors on the defeated side discredited the ethics of doctors in the eyes of public opinion in a way that is difficult to assess. It was necessary to start from scratch.
This was not difficult, given the climate of regeneration that reigned everywhere. In addition to rebuilding ruined cities, rehabilitating violated human rights, and replanting democracy in totalitarian deserts, medical ethics had to be revived so that atrocities such as those condemned at Nuremberg and Tokyo would never happen again.
The task was taken up by the newly created association World Medical Association, which, with its Declaration of Geneva, set out the guidelines for the medical ethics of the future. Promulgated in September 1948, three months ahead of the United Nations Universal Declaration of Human Rights, it thus established a new and universal medical-ethical order, valid for all and acceptable to all.
As far as we are concerned today, it is worth noting that the Declaration was presented to the medical world as a modern version of the Hippocratic Oath, which it replaced. The new formula could not have had a more acceptable appearance, for it not only translated the archaic clauses of the Hippocratic Oath into the language of the present, but was intended for the dual function which had hitherto been entrusted to the Oath. Namely: One, to serve as a ceremonial formula by which young graduates manifest their public commitment to abide by the ethical principles, and to live the noble traditions, of the medical profession. And two, to present to all the physicians of the world - of a world that, while secularised, was on its way to becoming a functional unit - a core of ethical ideals that bound together the traditions of the past and served as guide for the professional conduct of the future.
It was precisely this secularising and universalist intention that necessitated the mutation from oath to declaration. It was no longer possible to swear before divinity (before the gods of Olympus, Apollo and Asclepius, before the Triune God, before the One who dwells in Heaven, before Allah the Great). The new physician could only make his promises "solemnly and freely, and on his [word of] honour". The old religious and transcendent framework of the oath is exchanged for the new, secular and immanent one of the honourable promise.
This ensured its universal acceptance: the exclusion of the religious reference made atheists and agnostics happy and avoided disputes between professionals of different faiths. Believing doctors were not repulsed by the Declaration, since it prescribed an attitude of reverent respect for human life and the sick person, with unmistakably religious roots. After all, it is never necessary to swear an oath in order to commit one's own conduct, for it is enough that it is your yes, yes, and your no, no. Ethical respect, which is at the heart of the Declaration, could amount to both the Achtung of the Kantian theory of friendship and the core of Christian neighbourly love. It was all a matter of giving specific content to a deliberately undefined and polyvalent idea.
Not even 50 years have passed since the Declaration. But this almost half century has been more than enough for it to bring about a radical change in medical ethics. For example, sample, one clause of the 1948 Declaration suffices: "I will have the utmost respect for human life from the moment of conception". This categorical, absolute commitment has been abandoned. It began to soften when the World Medical Association ( association ) promulgated its Oslo Declaration on therapeutic abortion, a strongly restrictive declaration, which continued to uphold respect for human life, but which authorised the physician, faced with the dramatic and irremediable dilemma of saving only one of the two lives entrusted to him, to follow a systematic bias in favour of the life of the mother by causing the abortion. But it was in Venice in 1983 that, in order to reduce voluntary termination of pregnancy, already authorised by law in many countries, to an ethically neutral act, the Geneva clause was changed. From now on it will read: "I will maintain the highest respect for human life from the moment of its beginning". And the doctrine of free interpretation is officially established: each doctor decides for himself and for himself at what point he feels obliged to respect prenatal human life. With God absent, with his function as a witness of the doctor's actions suppressed, the highest respect has not stood the test of time. The circle of contempt for life, begun with abortion, is now closed with euthanasia.
2. The disappearance of respect for man
I think the case of disrespect for human life is very appropriate to be considered in this meeting on God in the internship, for sample with much drama how that change of framework, from Oath before God to Declaration for one's own honour, has caused a real Copernican turn in the Ethics of Medicine: Medicine is no longer a work that is done in the presence of God. God is no longer an unbribable witness of the doctor's actions. The doctor no longer has to adjust his conduct to the precepts of divine law; he is no longer necessarily the servant of life who bows reverently before the imago Dei in each patient. The doctor is the new, autonomous master of himself, who is guide with the compass of his honour.
Medical ethics is thus at the mercy of personal or consensual criteria, it is absorbed into the field of the forces of changing permissive legislation, economic powers, social conveniences and political situations. The two great respects, human life and the dignity of the patient, are subjected to a dynamic of negotiation, of price value, of quality standards.
Nothing reveals this better than the drama of euthanasia and end-of-life medical acts which, in just a few years, have acquired ethical citizenship in the Netherlands. It is not possible to recapitulate here the professional-ethical significance of Dutch euthanasia. Suffice it, however, to point out two aspects: some statistical data released by the successive reports of Attorney General Remmelink, and what I understand to be the patron saint of the escalation of violence by Dutch doctors against human life, a patron saint on four levels.
data statistics. Nine years ago, with the acquiescence of the judiciary, the Royal Dutch Society of Physicians issued apparently very restrictive rules for the internship of euthanasia. At the end of 1993, the professional rule became the Euthanasia Act. In 1994, the law was expanded for the first time: not only terminally ill patients with suffering for which there is no relief are candidates for legal euthanasia, but also those suffering from mental suffering for which there is no remedy or comfort to be found.
At the request of the Public Prosecutor, an acceptably rigorous programs of study has been published on the internship of euthanasia, financial aid suicide and what are called end-of-life medical acts. issue From the various published programs of study it appears, for example, that only 6% of doctors are totally against internship euthanasia; that the annual number of euthanasia cases is around 2000; that there are more than 1500 cases of medical financial aid suicide; more than 1000 cases of euthanasia in incompetent individuals (which is strictly forbidden by law), and that in about 40,000 cases end-of-life medical decisions were applied, consisting of fail or not starting treatment or applying excessive doses of opioids, all with the express intention of anticipating death.
In particular, general practitioners shorten the lives of more than half of their terminally ill patients. Of the patients who are euthanised, about 50% are involved in the process of deciding to end their life. Such involvement is not possible for 40 per cent, because of weakened consciousness or dementia, while the remaining 10 per cent are not allowed to do so for paternalistic reasons.
In the Netherlands, doctors cause more than a third of non-acute deaths. The shortening of these lives is often measured in hours or days; in many other cases, in weeks or months.
Escalating violence against human life. Reading the Attorney General's reports, it is possible to discern four levels of aggression against human life.
First level. Current Dutch legislation means to the letter that euthanasia is an exceptional form of treatment for certain patients, which is only authorised at their request and for extreme and very strictly regulated situations.
Second level. However, according to the common interpretation of the law, mercy killing is an accepted medical treatment, very popular, and so effective, clean, fast, economical, comfortable and aesthetic when compared to palliative medicine, that, in many cases, the doctor cannot morally refuse it when requested by the patient or his family.
Third level. Restricting legal euthanasia to patients who are capable of expressly and voluntarily requesting it is an inhumane and unjust legal requirement. For there are incapable patients who live in conditions of biological or psychological precariousness that are simply horrible. Those around, doctors or relatives say: "A reasonable person would never want to live like that. That is not life. It is preferable to die. The best thing for her is a sweet death". Doctors or relatives become, against the law, subjective mandataries of the insane old man, the comatose, the deficient neonate.
Fourth level. The utilitarian mentality inevitably leads to a consideration of this subject: There are individuals whose desire to go on living is irrational and capricious. The life ahead of them is simply detestable, lacking in quality. There is no hope of rehabilitation for them. To insist on living is therefore an unjust, unsupportive desire, with its irrational waste of economic and human resources: that money and that work effort could be far better spent elsewhere. It is a moral responsibility to end these lives.
Suffice it to recall a fact quoted above: 10% of euthanasias carried out by Dutch general practitioners are performed on conscious patients from whom, for paternalistic reasons, the intervention is concealed.
Euthanasia has been included in the Dutch medical literature internship . The correct handling of euthanasia drugs is discussed there, just as the correct use of antihypertensive drugs is discussed there. A monograph of the Royal Dutch Society of Pharmacy, entitled Euthanasia manager, insists on the need to search for the ideal euthanasia drug, a substance which, administered by different routes and free of undesirable side effects, ensures in 100% of cases a gentle, quick and peaceful death.
3. Why does the eclipse of God manifest itself so intensely in medicine?
It is obvious that something very serious is happening in medicine. Why? I think that in large part because of the forgetfulness of God, the specific dignity of the sick has been forgotten.
There is an expression of unclear origin that defines the sick person as Res sacra miser. The syntagm magnificently includes the two dimensions of dignity and impairment that accompany human illness. It is the sick person, a dignified but violated being, who moves the physician to intelligent compassion. In Christian medical ethics, no misery, regression or immaturity can obscure the presence and recognition of the dignity that dwells in the sick person.
Because the dignity of the patient is never lost sight of, it is possible to objectify the patient, to reduce him to an object of examination, to make him a thing to be explored as a mere biological reality, to be reduced to molecular and pathophysiological disorders. We doctors are allowed to pry into privacy in a way that is tolerated by no one else, because it is essential to reduce the biography staff of the patient to clinical anamnesis. The doctor has an open door to pry into the patient's misery. It is very easy then, as a result of the miserable vital and human quality of the patient, of the intellectual or organic impoverishment caused by the illness, for the doctor to lose sight of the sacredness of the patient, his intangible dignity as a person.
If God is not on the professional horizon, the idea that each human being has worth in his or her own right, that is, that God entrusts each and every one of us with a destiny, unique and unrepeatable, even if sometimes mysteriously miserable, becomes more and more remote. If, because God is taken out of the picture, the sacred dimension is removed and only the res miser remains, then human dignity changes sign, it becomes a negative dimension. The authors of euthanasia know this when they write on their banners "death with dignity for all" or join movements demanding the "right to die with dignity". Dignity no longer refers reference letter to the nobility inherent in every human being, to his or her condition of imago Dei, but to his or her psychological fullness, autonomous dignity, his or her score on the scales of quantitative indicators of humanity, the concept he or she deserves from others. The eclipse of God is followed by the eclipse of the sick man.
In Chapter I of his recent Encyclical Evangelium vitae, John Paul II analyses today's threats to human life by following the Genesis account of Cain's crime. The commentary reaches a dramatic peak when he comes to the murderer's words "I must hide from your presence". The Pope luminously entitles his commentary Eclipse of the meaning of God and man.
He says: It is necessary to get to the heart of the drama experienced by contemporary man: the eclipse of the sense of God and of man, characteristic of the social and cultural context dominated by secularism [...] Whoever allows himself to be infected by this atmosphere easily enters the whirlwind of a terrible vicious circle: lost the sense of God, one tends to lose also the sense of man, of his dignity and of his life.
And, further on, the Pope adds: "...as the Second Vatican Council lapidically states: "The creature without the Creator disappears.... Moreover, by forgetting God, the creature itself is obscured". Man can no longer be understood as "mysteriously different" from other creatures; he is seen as one of many living beings, as an organism that has at most reached a very high stage of perfection. Locked within the restricted horizon of his materiality, he is thus reduced to "a thing", and no longer perceives the transcendent character of his "existence as a human being". He no longer considers life as a splendid gift of God, a "sacred" reality entrusted to his responsibility and thus to his loving custody, to his "veneration". Life becomes simply "a thing", which man claims as his exclusive property, totally masterable and manipulable.
The quotation was long, although it could have been much longer, and included the whole of points 21 to 24 of the Encyclical. When I proposed the degree scroll, but not the substance of this intervention of mine, the Encyclical had not yet been published. I confess that when I read it, I felt the joyful sensation of seeing my poor ideas on topic lucidly, penetratingly exposed: that is exactly what I wanted to say.
Thank you very much.